Chiropractic Care of the Older Person: Developing an Evidence-Based Approach

0008-3194/2001/156–171/$2.00/©JCCA 2001 Chiropractic care

Chiropractic care of the older person: developing an evidence-based approach

Brian J. Gleberzon, DC*

Geriatric care has assumed a more dominant position in La gériatrie prend désormais une position plus the health care delivery system. This article discusses the dominante dans le système de distribution des soins results of a literature search on geriatric chiropractic médicaux. Le présent article examine les résultats d’une care with the ultimate goal of promoting a “best recherche documentaire sur les soins chiropratiques practice” approach. Fifty nine articles were found that gériatriques, dont l’objectif final consiste à promouvoir discussed geriatric chiropractic education (N = 3), une démarche basée sur les « meilleures pratiques ». demographic and epidemiological studies (N = 9), case On a repéré 59 articles qui portent sur : la formation studies (N = 25), clinical trials (N = 4) and clinical en chiropratique gériatrique (N = 3), les études guidelines (N = 18). The literature revealed that démographiques et épidémiologiques (N = 9), les études chiropractic pedagogy has recognized the importance of de cas (N = 25), les essais cliniques (N = 4) et les guides geriatric education, and epidemiological studies de pratique clinique (N = 18). La documentation révèle reported an increase in utilization rates of chiropractic que la pédagogie chiropratique a reconnu l’importance care by older persons, along with greater acceptance d’une formation en gériatrie, et les études within the medical community. Most older persons épidémiologiques rapportent une augmentation des taux sought out chiropractic care for neuromusculoskeletal d’utilisation des soins chiropratiques par les personnes (NMS) conditions, with several studies reporting the âgées, ainsi qu’une acceptation accrue de ce type de successful resolution of these conditions with spinal soins au sein de la communauté médicale. La plupart des manipulative therapy as well as an eclectic group of personnes âgées ont recours à la chiropratique pour other treatment interventions. Many older persons enter traiter les troubles du système neuromusculosquelettique, a maintenance care program, which they believe to be et plusieurs études rapportent la résolution de ces important to their health. Although the results of this troubles grâce aux manipulations vertébrales et à un article are encouraging, it underscores the need for ensemble éclectique d’autres traitements. Un grand continued research, especially in the areas of nombre de personnes âgées participent à un programme chiropractic maintenance care and the management of de soins légers qu’ils croient importants à leur santé. non-NMS conditions. Bien que cet article présente des résultats (JCCA 2001; 45(3):156–171) encourageants, il souligne la nécessité de poursuivre la recherche, particulièrement dans les domaines des soins chiropratiques légers et de la gestion des troubles qui ne concernent pas le système neuromusculosquelettique. (JACC 2001; 45(3):156–171)

KEY WORDS: geriatric, chiropractic, evidence-based MOTS CLÉS : gériatrie, chiropratique, médecine fondée medicine. sur l’expérience clinique.

* Assistant Professor, Canadian Memorial Chiropractic College, 1900 Bayview Avenue, Toronto, Ontario M4G 3E6. Tel.: 416-482-4478. Fax: 416-482-9233. E-mail: [email protected] © JCCA 2001.

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INTRODUCTION topics is also discussed. This includes; geriatric demo- Evidence-based medicine (EBM) has emerged as a con- graphics, utilization of complementary and alternative ceptual anchor term in health care. There is an expectation medical (CAM) services by older persons, attitudes within by health care stakeholders (patients, third party payers, the medical community towards CAMs, and a comparison and health care professionals) for an evidentiary founda- of the efficacy and safety of spinal manipulative therapy tion upon which health care decisions should be based. versus the use of NSAIDs for the treatment of spinal pain EBM has been defined by Sackett as the “conscientious, among older patients. Those therapeutic interventions that explicit and judicious use of the current best evidence in have been demonstrated to be efficacious for younger making decisions about the care of individual patients”.1 adults are cautiously applied towards the care of older He goes on to state that “evidence-based medicine means adults, and a brief summary is also included of those chiro- integrating individual clinical expertise with the best avail- practic technique systems that may be preferentially uti- able external clinical evidence from systematic research ... lized for the care of the older patient, as well as suggestions especially from patient-centered clinical research”.1 Thus, to modify the delivery of high-velocity low-amplitude the current best evidence is not limited to randomized (HVLA) manipulative “thrusting” type adjustments. clinical trials, but it includes anecdotal evidence, case studies, practitioner experience, and practice-based stud- RESULTS ies. This implies that procedures and behaviors have been Fifty nine articles were found that discuss issues germane subjected to rigorous standards of scientific observation, to chiropractic geriatric care within the search parameters. experimentation and documentation.2 Regrettably, this is These articles were further separated into the following not always the case and, in any event, little has been pub- categories: chiropractic geriatric education (N = 3), demo- lished to provide chiropractic clinicians with evidence- graphic/epidemiological studies (N = 9), case studies based guidelines for specific patient populations. This (N = 25), clinical trials (N = 4), and clinical guidelines should not be seen as an opportunity to chastise the chiro- (N = 18). Those articles that were only commentaries on practic profession. Indeed, using “evidence” to support the importance of chiropractic geriatric care were not in- practice patterns is a relatively new concept in health care, cluded in this summary. and it should be noted that only about 15% of the procedures used in mainstream medical practice have been stud- DISCUSSION ied using sound scientific methods.3,4 It should therefore not come as a surprise that “reasonable” patient care is Chiropractic geriatric education often delivered in spite of the absence of evidence of effec- The most significant articles on chiropractic geriatric edu- tiveness.4 As Altman and Bland opine, “absence of evi- cation document the process by which a “model curricu- dence is not evidence of absence”.5 Nevertheless, it is lum” for chiropractic educators was developed by Hawk important to develop a body of evidentiary knowledge in and Killinger et al.6–8 With funding from the US Health order to promote a “best practice” approach to chiropractic Resources and Service Administration (HRSA), this pro- geriatric care. This article is an attempt to promote an cess involved an interdisciplinary collaborative process to evidentiary basis for chiropractic care of older persons, design, compile and develop curricular resources.6 Inno- and provide appropriate information to support this ap- vative strategies, up-to-date assessment tools and recom- proach. mended readings were provided, as well as strategies to overcome barriers to the inclusion of chiropractors on METHODS interdisciplinary geriatric health care teams.6,7 This model A qualitative review of the literature was conducted, with curriculum has been implemented either in whole or in interpretation and synthesis by the author. The search strat- part at most chiropractic colleges.6,9 egy involved accessing Mantis, Medline and CINAHL databases from 1993–2000 (English Language) with the key words chiropractic/chiropractors/manipulation and geriatric/older patients/elderly. The literature on related

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Demographics and epidemiology Utilization of complementary and alternative medicines (CAMs) Population demographics Studies exploring utilization rates of chiropractic services According to some authorities who specialize in the field, by patients tend to be part of larger investigations into the demographics can explain two thirds of everything.10 utilization rates of complementary and alternative medical That is to say, if one understands the study of human (CAM) therapies in general. Although the term CAM is populations one can explain past events, understand cur- somewhat fluid in its application, it has generally come to rent trends and accurately prognosticate changes yet to mean the health care practices and professions that do not come. The importance of geriatric chiropractic care is pri- easily fit into the culturally dominant medical, educa- marily due to the confluence of two demographic trends; tional, and financial paradigms.14 the “rectangularization” of the population pyramid as the A demographic study by Eisenberg et al. revealed that result of the Baby Boomers and technological advance- almost 50% of respondents had been to a CAM provider, ments in health care, as well as the surge in utilization rates an almost 50% increase from his original study of a decade of complementary and alternative therapies (CAM) by pa- earlier.15,16 The researchers calculated that this repre- tients. sented an increase from 427 million total visits in 1990 to One of the most significant demographic changes in this 639 million visits (by 22 million people) in 1997, a number century has been the increase in human life expectancy. In that exceed the total visits to all US primary care physi- 1900 the average life expectancy in the United States was cians.15 The total cost for CAM providers was conserva- 47 years; in 1990 it was 75 years.7 Currently, in Canada tively estimated at $21.2 billion in 1997, with $12.2 billion and the United States, those over the age of 65 years repre- paid for by the patient out-of-pocket. The total out-of- sent about 12% of the total population.10,11 However, by pocket expenditures of alternative therapies of all kinds the year 2030, the number of those over the age of 65 is was conservatively estimated to be $27 billion.15 expected to increase to 20%. In real numbers, this amounts While certain therapies, such as herbal medicines, mas- to a total projection of 70 million American seniors by the sage, mega-therapy, self-help groups, folk medicine, en- year 2030, more than twice the number in 1990.6 ergy healing and homeopathy increased the most in the The Baby Boomers, those persons born between the decade between Eisenberg’s two studies, visits to years following the Second World War, from 1947 to chiropractors and massage therapists accounted for nearly 1966, represent the largest cohort group in many industri- half of all visits to CAM practitioners in 1997.15,16 alized countries.10 In Canada, the Baby Boomers represent Roughly 11% of respondents in the study sought out chiro- 34% of the population, or 10 million persons. America, practic care, and visits to chiropractors accounted for 30% Australia, New Zealand and Britain all have similar Baby of CAM total visits. An important finding was that less Boomer groups, but none is proportionately as large as than 50% of the respondents told their medical doctor they Canada’s.10 were under the care of a CAM provider.15 Of greatest significance, the fastest growing segment of The average demographic profile of a CAM user was the population is the “old” old, those over the age of 85.12 Caucasian, age 25 to 45 years, of higher education and of Indeed, the number of those over the age of 85 is predicted higher income than non-users of CAM services.15 The age to double between the years 1995 and 2000,12 and the group of highest utilization encompassed the Baby number of those over the age of 100 is expected to increase Boomers, and utilization of CAM providers for individu- 11-fold by the year 2050, when the number of American als over the age of 50 remained at 35% during the two centenarians is predicted to exceed 800,000.13 Given that different studies, which represented the largest demo- these groups of persons are more likely to experience com- graphic age group of users.15,16 A more recent study by plex morbific health profiles, the potential economic im- Shua-Haim and Ross17 also reported that utilization of pact on health care expenditures is enormous. CAM providers by older persons was increasing. Accord- ing to Shua-Haim and Ross, the most common forms of alternative or unconventional therapies utilized included: relaxation therapy, chiropractic, acupuncture, massage

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therapy and herbal/vitamin/mineral supplementation.17 Patients seeking out CAM care tended to have higher edu- The most common chief complaints that prompted pa- cation and income. Herbal remedies were the most fre- tients to consult a CAM provider were, in descending or- quently utilized CAM (60%), followed by old-time der: chronic low back and neck pain, anxiety, depression, remedies (47%), high-dose vitamins (41%), chiropractic, headaches, fatigue, insomnia, arthritis and sprains and massage and relaxation techniques (18% each) and special strains.15 Patients with back problems, neck problems, diets (12%).22 More recent studies of rheumatology pa- headaches, and sprains and strains were most likely to seek tients reported between 40.7% and 66% use of CAM.23 chiropractic care15 and, according to a practice pattern Similarly, a survey of 103 patients referred for rehabilita- analysis of Canadian chiropractors by Kopansky-Giles tion outpatient care revealed that 29.1% had used a CAM and Papadopoulos,18 chiropractors reported treating provider in the past 12 months.24 The most common 86.3% of their patients for primary conditions of a CAMs used were massage therapy, chiropractic, vitamins neuromusculoskeletal nature. and mineral supplementation and acupuncture.24

Utilization of chiropractic services by older persons Medical attitudes about complementary Coulter et al. have reported that older persons are over- and alternative medicine represented among chiropractic patients.19 In Canada (in Studies indicate there has been an increased interest in and 1994), the over 65 population comprised 14.1% of chiro- acceptance of CAM within the medical community. For practic patients while this group was only 8.7% of the total example, of the 117 (of 125) medical schools in the United population.19 If this ratio between population numbers and States that responded to a survey documenting information chiropractic utilization were to remain constant, when about CAM education within their curricula, 64% offered older patients comprise 20% of the total population, they some type of CAM instruction.14 Most classes offered could represent 25% of a chiropractor’s patient portfolio. were electives, although some institutions provided infor- The prevalence of low back complaints among older mation within required courses. Common topics included patients, although less than those age 45–65, is still high. chiropractic, acupuncture, homeopathy, herbal therapies, Bressler and Keyes et al.20 concluded that, while there is a and mind-body techniques. In another study, when asked, general under-reporting of the older population in the back 39% of medical physicians described chiropractic as a “le- pain literature, the prevalence of back pain in the elderly is gitimate medical practice”.14 between 13% and 49%, and cited a study of the rural eld- Contrary to popular opinion, studies indicate that pa- erly in Iowa that reported 22% of the respondents had tients are satisfied with the care they receive from medical experienced back pain during the past year. This is espe- physicians, and dissatisfaction with conventional medi- cially important when one remembers that neuromus- cine is not a predictor of CAM use.14 Lee and Kasper25 culoskeletal impairments are the most common chronic sought to assess the level of satisfaction with medical care condition causing activity limitation in the United States,19 reported by older patients in the United States. Overall, and increasing age has been associated with an increase in older patients reported high rates of satisfaction with the musculoskeletal symptoms.20 Consistent with these find- quality of medical care they receive, and satisfaction ings is the fact that the most significant increases in CAM rates approached 90% in areas such as overall quality of use were for patients with musculoskeletal problems and care, follow-up care, and information provided. Reported arthritis.15,16,21 satisfaction rates exceeded 90% in areas such as levels of Older patients with problems other than spinal pain also competence, understanding of patient’s medical history, seek out CAM care. In a prospective study of patients with diagnostic abilities, and thoroughness. However, older pa- prostatic carcinoma undergoing radiation therapy, 39% tients were less satisfied with medical care in some areas, were found to also use complementary health practices not and some reported that physicians seemed to be in a hurry, prescribed by their medical practitioners.22 In contrast, that they did not explain or discuss the patient’s problem physicians believed that only 4% of their patients used with them, and some patients felt that the doctor was “do- CAM providers. CAM treatment was continued even after ing them a favor” by examining them. One potentially initiation of definitive treatment for prostatic carcinoma. important finding of this study was that there appeared to

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be a negative association between the patient’s age and a who use Activator technique in this study, which was the favorable assessment of medical care.25 only professional organization who responded to the A practice pattern analysis by Ko and Berbrayer sought researcher’s recruitment efforts). Spinal manipulative to describe the attitudes and behaviors of Canadian physi- therapy (SMT) was the next most commonly used thera- cians with respect to CAM.23 In this study, 98 Canadian peutic intervention, with 23.5% of patients receiving this physiatrists were surveyed. Seventy-two percent reporting type of treatment. In addition to SMT, the most commonly referring to a CAM therapist (12.5% often), and 20% had administered procedures were recommendations for exer- training in and 20% practiced some form of alternative cise at least 20 minutes three times per week (41.0% of medicine. The therapists most highly rated in terms of patients), instruction on heat or cold application at home usefulness were acupuncture (85%), biofeedback (81%) (24.5%), and recommendations on food supplements and chiropractic (80%). Sixty-three percent of respondents (24.5%). Other procedures used less often include: ice thought alternative medicine had ideas and methods that packs in office (13.5%) ultrasound (12.3%), hot packs would be beneficial to physiatrists. Approximately 38.8% (11.3%), electrical stimulation, massage therapy, correc- of respondents believed CAM worked by the placebo ef- tive exercises and diet exercises (each used on under 10% fect, but only 9% of this group thought CAMs were a threat but over 5% of patients). Procedures used on fewer than to the public health. This contrasts with an earlier 1990 5% of patients were: acupressure, traction, orthotic fitting, study of Canadian family physicians that found that 21% recommendation of bed rest, acupuncture, recommenda- or respondents felt that CAM was a threat.26 Of interest, tions for weight loss and homeopathy. An important find- CAM referrals and utilization appeared to be higher in ing in this study was that pain medication use decreased younger, more recently graduated physiatrists.23 after 4 weeks of care among the group of patients who were discharged by the clinician, but not among those who Demographic profile of older patients patients who either self-discharged or were continuing seeking chiropractic care with care.27 A large practice-based research study by Hawk et al. The researchers concluded that musculoskeletal com- sought to characterize patients over the age of 55 who plaints composed nearly the entire case load of the presented for chiropractic care.27 This practice based re- chiropractors in this study, a finding consistent with other search study involved 121 chiropractors in Canada and the demographic studies. Moreover, the researchers con- United States. A total of 8,312 patients participated in the cluded that, based on the data collected, many patients study, 805 of whom were over the age of 55 years. The (66.6%) seek chiropractic care for conditions related to investigators reported that those patients in the study were only mild to moderate musculoskeletal complaints, predominately female (60.1%), white (94.7%), married whereas patients with more severe pain were more likely (66.3%), high school graduates (54.0%) and retired to seek both chiropractic and medical treatment.27 (68.0%).27 While the literature indicates that older patients initially The most common chief presenting complaint was back seek out chiropractic care for spinal pain, there is evidence pain, with 32.9% of patients reporting back pain in a single that patients continue with chiropractic care for reasons location, and 35.5% of patients citing multiple locations other than symptom relief. Surveys by Rupert sought to (such as “back and leg” or “neck and shoulder”).27 Most investigate the primary care health promotion activities complaints were chronic, with 54.9% of patients having associated with what has been historically termed “main- onset of symptoms more than 6 weeks before presenting tenance care” in both chiropractors28 and chiropractic pa- to the practitioner. Using a Pain Disability Index scale, tients over the age of 65 years.29 Maintenance care can be most patients reported their pain to be mild or moderate defined as periodic visits that seek to prevent disease, pro- in intensity.27 long life, promote health and enhance quality of life.30 In this study 56.6% of patients were treated using an Specific schedules of treatment are theoretically designed Activator, a mechanical manually-assisted instrument that to provide for a patient’s well-being or for maintaining generates a low-force high-velocity thrust (this finding is their optimum state of health. Maintenance care is pro- undoubtedly related to the participation of chiropractors vided to a patient irrespective of clinical symptomatology.

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Six hundred and fifty-eight chiropractors were sur- three percent of older patients were treated to control or veyed, and their attitudes relating to the importance of prevent musculoskeletal conditions, 31.2% visceral prob- maintenance care were compiled.28 Notwithstanding the lems and 73.3% for subluxations. Other trends reported by absence of any scientific proof, the majority of American patients receiving maintenance care were a reduced need chiropractors who responded to the survey believed in the for hospitalization, as well as reduced health care costs. In value of maintenance care for patients of all ages for a fact, the total annual cost of health care services for older variety of conditions ranging from stress to musculoskel- patients receiving maintenance chiropractic care was con- etal and visceral conditions, with 79% of chiropractic servatively estimated at only one third the expenses re- patients receiving recommendations to enter a mainte- quired by American citizens of the same age who did not nance care program. Ninety percent of respondents receive maintenance care. Lastly, there was a significant (chiropractors) agreed or strongly agreed with the state- positive correlation between reduced use of nonprescrip- ment that the purpose of maintenance care was to optimize tion drugs and the number of years under chiropractic health, 88% stated it was to prevent conditions from de- maintenance care.29 veloping, 86% reported they were providing palliative One of the most important findings in this study was the care and 95% believed they were minimizing recurrences response by older patients when asked: “How important do or exacerbations.28 Similar studies in England and Aus- you feel chiropractic treatment has been in maintaining tralia found that chiropractors in those countries also sug- and promoting your health?”. An overwhelming 95.8% of gested maintenance care for a significant portion of their patients believed that maintenance care was either consid- patients.28 erably or extremely valuable to their health.29 In a companion study, Rupert et al. sought to investigate With the exception of total annual visits to medical doc- the multiple health issues of those chiropractic patients age tors, results from the studies by Rupert et al. closely paral- 65 and over who have had a long-term regimen of mainte- lel the findings of earlier studies by Coulter et al.19 In their nance care.29 The study reported that elderly patients studies, Coulter et al. reported that a small cohort of older receiving maintenance care did not rely solely on chiro- chiropractic patients were less likely to have been hospital- practic care but instead utilized both medical and chiro- ized, less likely to have used a nursing care facility, more practic services. The average number of visits to medical likely to report a better health status, more likely to exer- doctors by patients age 65 and over while under chiroprac- cise and were more likely to be mobile in their communi- tic maintenance care was 4.8 visits per year, which was ties. In addition, chiropractic patients were less likely to approximately half the national average of 9 visits per use prescription medications.19 Of course, this may speak year.29 This finding differs from previous studies by Coul- more to the general behavior of those patients who seek ter et al.18 that concluded chiropractic care complemented out chiropractic care rather than any benefits directly de- rather than replaced medical care. rived from chiropractic treatment. According to Rupert’s study, most chiropractors utilized Diversified techniques (70.4%) for older patients Case studies receiving maintenance care.29 Other techniques used in- Twenty-five case studies discussing the management of 20 cluded: Activator (28.3%), Thompson terminal point different clinical conditions were found within the litera- (21.9%), Nimmo/soft tissue techniques (20.6%), Applied ture search. Many studies detailed the successful resolu- Kinesiology (16.1%) and Sacro-Occipital technique tion of various conditions affecting older persons while (13.5%).29 It should be noted, however, that chiropractic under chiropractic care. Conditions successfully treated maintenance care did not solely consist of periodic visits included cervical spondylotic radiculopathy,31 diffuse idi- for joint manipulation, but it included an eclectic group of opathic skeletal hyperostosis (DISH),32 dislocation of the interventions such as exercise, nutritional advise, relaxa- sternal-clavicle joint,33 rotator cuff tear,34 vertigo and tin- tion, physical therapy and manipulation directed at both nitus,35 thoracic outlet syndrome,36 myastenia gravis,37 musculoskeletal and visceral conditions.29 diabetic neuropathy with involvement of the tarsal joints,38 Thirty-eight percent of older patients were treated for spinal stenosis39 and post surgical repair to the quadriceps chronic health problems, while 61.7% were not.29 Eighty- muscle.40 Two articles41,42 discussed the positive benefits

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of chiropractic care for general rehabilitation of older per- and osteopathic manipulation had reduced antibiotic use sons following injury, such as a Colles’ fracture.41 Another and decreased length of hospital stay.58,59 article discussed the successful management of an older patient with left hip, leg and low back pain attributed to Clinical guidelines osteoarthritis and a structural short leg using a heel lift and Eighteen articles provided practitioners with clinical osteopathic manipulation.43 guidelines with respect to different health concerns con- Other studies described cases of older patients present- fronting older patients. Topics discussed in the literature ing with spinal pain that were later attributed to prostatic included: principles and challenges of assessing the older metastasis,44,45 bronchial carcinoma,46 or abdominal aortic patient,60–64 the Five “I’s” of geriatric care,65 assessment aneurysms.47,48 In each of these cases, the authors empha- of peripheral neuropathy,66 issues pertaining to falls, inju- sized the importance of appropriate medical referral, and ries and trauma,67 elder abuse,68 exercise,69 diet and nutri- the importance of including such pathologies in any differ- tion,70,71 the importance of strength training,72,73 special ential diagnosis when assessing older persons for present- considerations for spinal manipulative therapy74 and other ing spinal pain. Other articles described the development associated patient management issues as they pertained to of cerebellar infarct49 and Jefferson’s burst fracture50 in older patients.75 Other articles described special consid- older patients following motor vehicle accidents. One arti- erations concerning plain film radiography,76 and one article described the development of a fracture of the femoral cle discussed the presentation, diagnosis and management neck subsequent to radiation therapy,51 and two articles of abdominal aortic aneurysms.77 described cases of low back pain with radiculopathy Many of these articles stressed the importance of moni- eventually diagnosed as synovial facet joint cysts.52,53 toring both quantitative and qualitative measures in older Cases of older patients with chrondrosarcoma and myosi- patients. Bowers has stressed that functional assessment is tis ossificans54 and thalamic pain syndromes55 were also the cornerstone of geriatric assessment,60 while Killinger reviewed. has suggested that “whereas a provider must be desirous of facilitating the patient’s progress in terms of improved Clinical trials scores on outcome assessments and return to normal Most clinical studies on chiropractic adjustive therapies ranges of motion, the [older] patient’s goal may be much exclude by design geriatric patients. It is therefore not sur- more straightforward- independence”.67 This concept is prising that only four clinical trials specifically involving echoed by Hoffman78 who suggested that a clinician orient older persons were found within the literature search.56–59 a patient away from the exclusive goal of pain manage- However, all four studies investigated the benefits of ment, and instead should emphasize the importance of re- “osteopathic manipulation” on older patients. These stud- storing a patient’s functional ability. In this words, ies sought to measure changes in bowel habits,56 preva- “patients should be made to understand that as function lence of falling,57 or the effects on patients with returns pain will decrease, rather than as pain decreases pneumonia.58,59 Osteopathic manipulation differs from function will resume”.78 This follows earlier models de- chiropractic manipulation in that the former is more of a veloped by Waddell who posited that “treatment often fails mobilization (a low-velocity, low amplitude maneuver when relying on too narrow a conceptual model of pain”.78 within the active range of motion), whereas a chiropractic This shift away from a pain-based model to a functional- manipulation (or spinal adjustment) is a high-velocity, based model is nowhere more important than in the care of low-amplitude thrust into the paraphysiological space older patients, whose painful symptoms are often the result (Cooperstein R, personal communication). The introduc- of degenerative, irreversible conditions. tion of osteopathic manipulation was not shown to have a measurable influence on the frequency of patient-falls Clinical trials of spinal manipulative therapy compared to interdisciplinary assessments,57 nor were A great deal has been written on the efficacy and effective- changes in bowel habits recorded resulting from osteo- ness of spinal manipulative therapy for functional spinal pathic manipulations.56 However, those patients with pain. Mootz and Meeker have compiled an extensive body pneumonia receiving both conventional medical treatment of evidence supporting the utilization of spinal manipula-

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Table 1 tive therapy for acute and chronic back pain (Table 1) Brief Overview of Research Findings (Mootz RD, Meeker, WC unpublished work). However, as on Spinal Manipulation previously mentioned, many of these clinical trials into the (Mootz RD, Meeker WC)* efficacy of SMT for back pain have been conducted on younger adults, and the extrapolation of the results from • Acute low back pain: 14 RCTs these studies to older patients must be done with caution. 7 favored manipulation, Older patients often have complex health histories, and 4 found significance in subgroups, typically exhibit equally complex physical findings. None- 3 found no difference theless, the assumption that SMT should be as effective for • Subacute and chronic LBP: 13 RCTs spinal pain in an older patient as it is for younger patient is 5 favored manipulation over the other treatments not arbitrary or unreasonable. Similarly, clinical trials sup- 3 reported no significant differences port the use of SMT for tension and migraine head- 1 made no conclusion from the data aches,79–82 fibromyalgia,83 and cervical vertigo.84 The judicious use of SMT for the successful management of • Mixed LBP: 13 RCTs these conditions, if encountered in an older individual, are 9 favored manipulations likely to be as clinically effective. 1 significant in subgroup only Bronfort85 has recently compiled the evidence for the 3 reported no difference use of SMT for headaches as well as acute and chronic • Manipulation vs placebo: 11 RCTs (4 sham neck and low back pain, and has reviewed the clinical manipulation, 7 detuned modalities) guidelines from the United States, United Kingdom, Aus- 8 favored manipulation (including 4 of the 5 best tralia and Sweden (Table 2, 3). Taken as a whole, the designed studies) clinical guidelines from these different countries advocate the use of SMT for acute and chronic low back pain, and • Acute and chronic neck pain: 10 RCTs chronic neck pain. The evidence also supports the use of 4 favored manipulation SMT for chronic headaches. Recommendations for the use 6 no statistical difference of SMT for acute neck pain are weaker as compared to the Statistical pooling of 5 better studies yielded a strength of the other recommendations.85 It is noteworthy 0.06 effect size favoring manipulation that a chiropractor was not part of the committee that de- (a change of 16 on 100 pt. scale) veloped the clinical guidelines in Australia or Sweden.85 • Headache: 8 RCTs 5 favored manipulation (muscle tension/ Adverse reactions to cervicogenic) chiropractic therapeutic interventions 3 equivocal (migraine, chronic muscle tension) There is very little age-stratified data on the frequency of adverse reactions to spinal manipulative therapy. Senstead Code: RCT: randomized clinical trials, LBP low back et al. conducted a practice-based survey to detail the pain frequency and characteristics of side effects of spinal * Adapted with permission from Mootz RD, Meeker WC. An evi- manipulative therapy.86 The information regarding un- dence-based update on spinal manipulation with considerations pleasant reactions after SMT was collected after 4,712 for an aging population. Proceedings, National Symposium on Complementary and Alternative Geriatric Health Care and Geri- treatments on 1,058 new patients by 102 Norwegian atric Research and Clinical Center Symposium, St. Louis Uni- chiropractors. The incidence of side-effects to SMT was versity School of Medicine and Logan College of Chiropractic. 49% among patients age 47–64 years of age, and 60% St. Louis, MO, April 2000 (public domain). among patients 27–46 years of age. At least one reaction was reported from 55% of patients at some time during the course of the maximum 6 treatments. Of reported reactions, the most common were local discomfort (53%), headache (12%), tiredness (11%), or radiating discomfort

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Table 2 Summary of efficacy of SMT for Low Back Pain based on systematic reviews and evidence-based national clinical guidelines (85)* Study Acute Low Back Pain Chronic Low Back Pain Anderson et al., 1992 + + Shekelle et al., 1992 + ? US guidelines, 1994 + N/A Koes et al., 1996 ?/+ ? Bronfort et al., 1997 + + van Tulder et al., 1997 (+) + Australia Guidelines, 1999 (+) N/A United Kingdom Guidelines, 1999 + N/A Swedish Guidelines, 2000 + +

Code: + indicated recommended, (+) some evidence to suggest, N/A not commented/ not available, – not recommended.

Table 3 Summary of efficacy of SMT for Neck Pain and Headaches based on systematic reviews and evidence-based national clinical guidelines (85)* Study Acute Neck Pain Chronic Neck Pain Headache UQTF-WAD, 1995 ?/+ ?/+ N/A Aker et al., 1996 (+) (+) N/A Hurwitz et al., 1996 + + + Bronfort et al., 1997 ? + + Kjellman et al., 1999 (+) + + Vernon et al., 1999 N/A N/A (+) Swedish Guidelines, 2000 (+) ? N/A

Code: + recommended, (+) suggested, N/A not available, ? undetermined * Reprinted with permission of the author.

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(10%). Reactions were either mild or moderate in 85% of with stroke following spinal manipulation. The authors of cases. Sixty-four percent of reactions appeared within this article concluded they could not definitively state 4 hours of the treatment, and 74% disappeared with 24 which of the factors were in and of themselves absolute hours. Uncommon reactions reported were: dizziness, risk factors for stroke. For example, strokes were found to nausea, hot skin or “other complaints”, each accounting occur more commonly among younger adults, but it is this for 5% or less of reactions. These unusual symptoms typi- group of persons that are most likely to receive chiroprac- cally commenced later than on the day of treatment, were tic manipulation or to be exposed to major or minor of long duration, were reported as severe in intensity and trauma. Furthermore, the authors ultimately concluded resulted in reduced activities of daily living. There were no that, because the event is so rare, and the literature re- reports of serious injuries or complications during the viewed is often lacking critical details, it is impossible to study.86 Lastly, it should be noted that not one of the sev- advise patients or practitioners about how to avoid the risk eral dozen randomized clinical trials of spinal manipula- of stroke during manipulation, nor could they be specific tion has ever reported an experimental subject to have as to which sports or exercise activities result in neck been injured, which would have been required if any injury movements or trauma of greatest potential risk. Moreover, had occurred.87 because chiropractors perform 90% of all therapeutic cer- Recently, Cooperstein and Killinger have reviewed the vical manipulations, it is to be expected that the majority available literature pertaining to chiropractic technique in of these injuries are more commonly associated with the care of the geriatric patient.87 Based on their review, chiropractors.88 these authors concluded that older patients do not appear to The literature provides examples of stroke following suffer more adverse reactions to spinal manipulation than major traumas (motor vehicle accidents, falls, sports inju- younger patients, and they may even suffer fewer. They ries and so on), minor traumas (walking, star gazing, yoga) opine this may be attributable to both patient-variables and during such seemingly benign activities as kneeling (perhaps the greater joint stiffness often found among at prayer, household chores and sexual intercourse.88,89 older persons may in fact protect them from injury related Thus, the age of the patient is not a relative or absolute to poorly-directed or excessive force), doctor-variables contraindication to cervical manipulation. It should also be (perhaps greater reliance on low force techniques, and noted that, although aneursym is invariably listed as an more prudence exercised by the clinician) or a combina- absolute contraindication to manipulation, there has yet to tion of the two.87 be a single documented case report of manipulation result- Spinal manipulative therapy is not without material ing in a bleeding event related to aneursym.87 risks, but the evidence suggests that such risks are rare Manipulative therapies are often modified in response and remote. Among the most serious outcomes is stroke to patient tolerance or circumstances, and specific consid- following cervical manipulation, which is a tragic, yet erations have been reported in chiropractic literature.74,78 fortunately rare event. The stroke is usually the result of a In their article discussing manipulative care of the older dissection of the vertebrobasilar artery. Current accepted person, Bergmann and Larson stated that “consideration estimates of the frequency of a stroke resulting in serious can be given to the use of specific, high-velocity low- neurological complications or death following manipula- amplitude thrust technique in the care of the older tion are between 1 and 3 million adjustments and 400,000 patient”.74 Similarly, Winterstein commented that “ma- patients.88,89 The most commonly accepted estimate of the nipulative management of the geriatric patient is rarely risk of stroke following manipulation is 1 in 1,000,000 contraindicated, but use of any adjustive procedure must patients.90,91 A study by RAND91 further estimated the rate be tempered by age-related factors, such as the presence of of serious complications from spinal manipulation to be 5 compression fracture, use of anti-coagulant medication, to 10 in 10 million for vertebrobasilar reactions, 3 to 6 in osteopenia and other modifiers”.92 Thus contraindications 10 million for major impairments, and an incidence of less to SMT are predominately condition-specific rather than than 5 fatalities per 10 million manipulations. age-specific. The author refers the reader to the textbook An extensive review by Haldemann, Kohlbeck and by Bergmann, Peterson and Larson93 for a comprehensive McGregor88 sought to identify the risk factors associated list of relative and absolute contraindications to SMT.

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Cooperstein and Killinger have suggested that the issue ated with the normal aging process. As a person ages, there surrounding the safe delivery of a manipulative thrust to an is a decline in both hepatic and renal function.95 By age 80, older person may be less one of force and more one of there is a 30% (or more) decline in glomerular filtration pressure.87 For patients with osteopenic disease, the au- rate, renal mass and blood flow and also a decline in he- thors posit that a manipulative thrust should be delivered patic mass, enzymatic activity and blood flow.95 These over as broad an area of the spine as possible. For example, physiological changes culminate in a decline in drug clear- a practitioner may deliver a Carver bridge adjustment ance and an increase in a drug’s bioavailability. (knife-edge or hypothenar contact on the patient’s thoracic Thirty percent of all prescription drugs, and forty per- spine while the patient is prone) with ample force for cent of all over-the-counter drugs, are purchased by adults therapeutic effect provided that several vertebral segments over the age of 65 years.96,97 Two-thirds of Americans are contacted, as opposed to contacting only one vertrbral over the age of 65 use at least one drug a day, with 45% of segment. Similarly, leverage must also be considered dur- the elderly taking several prescriptions concurrently.97 ing the delivery of thrusting-type adjustments, especially Risks of NSAID use include serious gastrointestinal in the area of the costovertebral joints.87 (GI) complications such as gastritis, ulcers, perforation Several chiropractic technique systems provide alterna- and bleeding.98 Complications from NSAID use has been tives to HVLA manipulative adjustments, which may be of calculated at 0.04% fatality rate, accounting for 3,200 particular benefit when treating a patient with advanced deaths annually,99 and a 2.74% rate of serious GI osteopenic or osteoarthritic diseases. Chiropractic tech- events.100 Other studies estimate 2,600 deaths and 20,000 niques that may be efficacious for these patients include hospitalizations annually are attributable to NSAID use, instrument-assisted techniques (i.e. Activator), blocking with an incidence rate of 390-3200 serious GI events per techniques (i.e. SacroOccipital Technique), drop-assisted million.101,102 NSAIDs have other side effects such as hy- techniques (i.e. Thompson Terminal Point), mechanically- pertension, they may interfere with hypertensive therapy, assisted techniques (i.e. Cox Flexion) or upper cervical and NSAID use is associated with an increased risk of techniques (i.e. NUCCA).87 renal insufficiency, especially if combined with medications such as diuretics and certain cardiac drugs.98 Adverse reactions to medical therapeutic interventions About one half of all deaths attributable to ADRs occur It is reasonable to compare the risks associated with chiro- in persons age 60 and over.97 Between 10% and 17% of all practic management of spinal pain to the risks associated hospital admissions in the elderly are the result of inappro- with medical management of spinal pain. For the treatment priately used prescription medication.95,97 The annual na- of spinal pain among patients of all ages, medical physi- tional cost of drug-related morbidity and mortality has cians most commonly prescribe pharmacological agents recently been estimated at $76.6 billion, with the majority as their primary therapeutic intervention. Medications ($47 billion) related to hospital admissions.103 A prospec- such as non-steroidal anti-inflammatory drugs (NSAID) tive meta-analysis conducted by Lazarou et al sought to are among the most commonly prescribed drugs for spinal estimate the number and incidence of serious and fatal pain. The incidence of adverse reactions to these and other adverse drug reactions in hospitalized patients in the drugs is regrettably high, and the evidence suggests that United States.94 The researchers reviewed prospective the sequella of these adverse risks are not trivial. data obtained over a 32 year period on two different An adverse drug reaction (ADR) is defined as any nox- groups; those admitted to hospital due to ADRs, and those ious, unintended, or undesirable effect of a drug, which experiencing ADRs while in the hospital. The authors esti- occurs at doses used in humans for prophylaxis, diagnosis mated that, in 1994, 2,216,000 patients in the two groups or therapy.94 This definition excludes therapeutic failures, studied had a serious ADR, and 106,000 had fatal ADRs, intentional and accidental poisoning (drug overdoses), er- making these reactions between the fourth and sixth lead- rors in administration or non-compliance on the part of the ing cause of death in the United States, a ranking higher patient.94 than either pneumonia or diabetes.94 Other studies has in- Older patients are particularly vulnerable to adverse vestigated the incidence of ADRs in hospitalized pa- drug reaction because of the physiological changes associ- tients,104–107 and patients in nursing care facilities108–112

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with results that were as equally disturbing. The perceptions held by medical practitioners as to the effectiveness of chiropractic care is becoming more posi- Cost-effectiveness of chiropractic care tive, and medicine as a profession is becoming more and There have been no studies specifically assessing the cost- more interested in the field of CAM. This bodes well for effectiveness of chiropractic care for older patients. How- the impetus towards an interdisciplinary approach to ever, as previously described, Rupert29 reported that the health care which depends on many different health care total annual cost of health care services for those older providers working together. patients under chiropractic maintenance care was esti- Older patients receiving chiropractic care tend to use mated to be only third the expense by American seniors fewer prescription medications, are less likely to have used not under maintenance care. Other studies, such as the one nursing care facilities, and are more likely to report a better by Manga,113 concluded chiropractic care was a cost- health status. Patients who seek chiropractic care tend to effective, safe and effective treatment approach. be members of the Baby Boomer demographic group and of higher income and higher education than those persons CONCLUSIONS not under chiropractic care. Based on the literature, several conclusions can be de- Although many patients initially present to a chiro- duced. As a profession, chiropractic has recognized the practor with spinal pain, they often continue with treat- importance of geriatric education, and the Model Curricu- ment for reasons other than symptom relief. Such reasons lum has served as an important vehicle to standardize this include disease prevention, prolongation of life, health education. As well, several articles have been written that promotion and enhancement of quality of life. Even provide clinicians with guidelines in many different areas though there is no evidence to support that any of these of health care on the successful management of older pa- benefits occur, almost all older patients receiving chiro- tients. Other articles have alerted clinicians to the possibil- practic maintenance care believed it to be important to ity that a seemingly uncomplicated case of low back pain their health. may in fact be secondary to other pathological conditions The most common therapeutic intervention used by a that preferentially affect this group of persons, such as chiropractor is spinal manipulative therapy. The best cancer or abdominal aortic aneursyms. These articles have available research supports the use of SMT for acute and emphasized that chiropractic clinicians must be vigilant to chronic low back pain, acute and chronic neck pain and these possibilities, and that many pathological conditions certain types of headaches, and it is reasonable to extrapo- are best primarily managed by experts in the medical pro- late these findings to the treatment of older adults. The fession. literature indicates that SMT is a safe and cost-effective Demographic projections indicate that the population is treatment for spinal pain, with the risk of serious injury aging at an exponential rate. At the same time, patients in being remote. This is especially evident when the safety of general, and older patients in particular, are more com- SMT is compared to the incidence of adverse drug reac- monly seeking out complementary and alternative medi- tions associated with the use of NSAIDs, the most com- cines. These findings have led Killinger to conclude that monly used treatment modality by medical providers for “our nation must recognize that health care is becoming the management of spinal pain. With regards to the admin- primarily geriatric health care and will remain so for quite istration of SMT, many authorities would agree that some time”.6 The most common reason to seek out CAM chiropractors are the best trained health care providers to is for spinal pain of mild to moderate intensity. The preva- safely and effectively deliver this form of manual therapy. lence of back pain among the older adult population is The literature also indicates that chiropractic practitioners high, and back pain has important negative ramifications promote several healthful lifestyle choices for their older both in terms of a person’s health and the economic burden patients including nutritional advice, stretches, exercises to the health care system. The most commonly consulted and strengthening program recommendations. This holis- CAM provider for this condition is a chiropractor, al- tic approach resonates well with current trends in health though chiropractic and other CAMs are often a comple- care promotion and prevention.114 ment to rather than a replacement for medical care. Anecdotally, older patients have also been successfully

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